Inpatient Precertification Requests for Out-of-State Providers

Permedion is responsible for reviewing the medical necessity of Inpatient Psychiatric Precertification requests. It is our intention to make this process as simple and expedient as possible, while effectively addressing the unique needs of both providers and recipients.

Out-of-state inpatient psychiatric providers are frequently unfamiliar with Permedion’s Utilization Review process and documentation needs, as well as how to use the Ohio Medical Information Technology System (MITS). Permedion understands this and accommodates a provider’s need to learn the procedures and get established in MITS. The following information is helpful to understand how to proceed.

Please Note: Precertification for detox services, whether inpatient or outpatient, are not required. However, if upon admission other mental health services are identified as being needed, appropriate precertification should be requested.

Medicare Primary

If a recipient has Medicare primary at the time of admission, providers do not need to request precertification for inpatient psychiatric admissions.

Medicare benefit exhausts and the provider wishes to bill Medicaid, the case must be entered into MITS for retrospective review. The MITS eligibility screenshot must be uploaded into the MITS case. In the event the MITS screenshot is not available, date stamped documentation from the medical record that Medicaid eligibility and Medicare benefits were checked within two business days of admission must be uploaded into MITS. In this instance, the Permedion precertification form is not required. This also applies to QMB/QMB Plus and My Care Ohio recipients.

Recipients in Managed Care Plans (MCP) should seek authorization from the MCP. Exception: if the provider is a freestanding psychiatric facility, precertification requests must also be reviewed by Permedion via MITS.

Clinical Documentation

The Permedion nurse reviewers are committed to making timely, well-informed determinations. They rely on providers to submit comprehensive, detailed documentation to ensure this. It is to the advantage of providers to present a clinical picture that adequately reflects recipient need, as well as the specific benefit derived as a result of inpatient psychiatric hospitalization. The provider must make evident why inpatient psychiatric hospitalization is medically necessary.

Medical Necessity

The primary purpose of Permedion Utilization Review is to determine medical necessity. Permedion encourages providers to regularly review with employees what constitutes medically necessary services, as well as how to adequately document medical necessity on the Inpatient Psychiatric Precertification form.

Documentation Quality

The quality of clinical documentation provided on the Inpatient Psychiatric Precertification form directly impacts whether or not a case is approved. A hospital’s efforts to establish medical necessity are best supported through high quality documentation. Please follow this process in your documentation:

Answer all questions.

Provide specific examples of patient emotional and behavioral symptoms, as well as psychosocial and environmental problems.

Specifically address why the patient is unsafe toward self and/or others and is unable to sufficiently care for self.

Explain why hospitalization is the best course of treatment verses other alternatives. i.e. partial hospitalization. If other intensive treatment options are plausible, but unavailable within the community, and the patient’s mental health status is not conducive to a lower level of care, explain this.

Provide examples of outpatient interventions that were trialed prior to the inpatient psychiatric admission.

Give detailed information regarding anything else of importance that led to the patient’s decompensation and subsequent need for hospitalization. i.e. recent crisis or trauma.

Documentation Quantity

The amount of information provided on the Inpatient Psychiatric Precertification form is at the discretion of providers. However, it is recommended that care be taken to ensure a quantity sufficient to support medical necessity. The expandable fields should be well utilized. Typically, more information is better, however, ensure that it is relevant to the current request.

Submission Deadlines

Effective May 1, 2015, providers are granted two (2) business days from a patient’s psychiatric admission date to submit the Inpatient Psychiatric Precertification Form. On submissions made prior to April 30, 2015, providers had only one (1) business day to submit.

Holiday Submission Deadlines- On a state-recognized holiday, the holiday is treated the same as a weekend day. The deadline is always two (2) business days, and does not change due to a holiday. For instance, if the holiday falls on a Friday, then a case that comes in on Thursday would need submitted no later than Tuesday. On a non-holiday weekend, the same case would need submitted by Monday. If the holiday falls in the middle of the week, then that would also extend the due date by one day.

In order to prevent technical denials (aka administrative denials) due to lack of timeliness, it is important for providers to distinguish state recognized holidays from those that are not.

State of Ohio 2016 holiday schedule:

New Year’s Day- 1/1

Martin Luther King, Jr. Day- 1/18

President’s Day- 2/15

Memorial Day- 5/30

Independence Day- 7/4

Labor Day- 10/5

Columbus Day- 10/10

Veteran’s Day- 11/11

Thanksgiving- 11/24

Christmas- 12/26

Inpatient Psychiatric Precertification Form

In order to ensure that a hospital is submitting the most current request form, it is recommended that a new form be downloaded every time a new precertification is needed. Additionally, always press F5 on the computer keyboard in order to clear cookies, thus ensuring the most current website information and form are available.

Ohio Medical Information Technology System Access (MITS)

An integral part of the inpatient psychiatric precertification process involves the use of MITS. Within MITS providers must enter admission information and upload Permedion’s precertification form.

Providers who do not have access to MITS must complete the enrollment process.

MITS enrollment process for users with a Medicaid provider number click here.

MITS enrollment for users without a Medicaid provider number click here.

It is advantageous for providers to know the process related to making Inpatient Psychiatric Precertification requests. Not only does it aid in knowing what to expect from Permedion, but also enables the hospital to develop internal procedures for best managing the precertification requirements. The following is the Utilization Review process for Inpatient Psychiatric Precertification requests:

Inform Permedion by calling 855-974-5393, at which time a fax number will be provided.

Fax the precertification form to Permedion.

PLEASE NOTE: Although in receipt of the precertification form, Permedion cannot provide utilization review until the provider has gained access to MITs and completed all the necessary information regarding the precertification request.

Upload the Inpatient Psychiatric Precertification form into MITS.(Instructions)

Utilization review for inpatient psychiatric precertification requests do not require the entire medical record and in compliance with HIPAA should NOT be submitted.

Once the Permedion nurse reviewer receives a properly completed Inpatient Psychiatric Precertification request, a determination is made within three (3) business days.

When a precertification request is approved, a letter indicating such is mailed to both the provider and patient.

When a precertification request is denied, a letter indicating such is mailed to both the provider and patient. The provider denial letter includes appeal instructions.

Only under extraordinary circumstances should inpatient psychiatric admissions be sent to Permedion for Retroactive Utilization Review.

In order for Permedion to process retroactive requests, proof must be established that the facility checked Medicaid eligibility at the time of admission, and recipient became Medicaid-eligible after admission. To do this, upload date-stamped proof of eligibility instead of uploading into MITS the Inpatient Psychiatric Precertification form. It is recommended that proof be the MITS eligibility screen.

Hospital Observation Beds

When an inpatient psychiatric hospital places a patient in a 23-hour observation bed and then releases the patient within 23 hours, no precertification is required. However, if the patient is admitted to the hospital from observation, precertification must be completed as usual within two business days from the date of admission

Readmissions Within 1 Calendar Day of Discharge

In accordance with Ohio Administrative Code 5160-2-02, a readmission within one calendar day of discharge, to the same institution, is considered to be one discharge for payment purposes so that one DRG payment is made. If two claims are submitted, the second claim processed will be rejected. In order to receive payment for the entire period of hospitalization, the hospital will need to submit an adjustment claim reflecting services and charges for the entire hospitalization.

Protected Health Information

Inpatient Psychiatric Precertification and Retroactive Utilization Review requests should not include the entire medical record. Personal health information (PHI) is protected by law in order to support patient privacy. Permedion and providers should work together to ensure that unnecessary records not be shared.

A central aspect of the privacy rule is the principle of “minimum necessary use” and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of PHI needed to accomplish the intended purpose. A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum necessary standard applies, a covered entity may not use, disclose or request the entire medical record unless it can be specifically justified.

Taking the privacy rule into account, Permedion does not request providers to send full medical records for Inpatient Psychiatric Precertification or Retroactive Utilization Reviews of Psychiatric Inpatient admissions.

Change of Contact

As needed, hospitals should contact Permedion with any primary contact changes. Permedion’s experience has been that sometimes the proper hospital personnel do not receive correspondence on a timely basis because it was delivered to the incorrect person.